Medical Authorization Form

Name :-
Date:- 
I, the undersigned here by grant permission to Triune physiotherapy to obtain any medical information regarding my physical of mental health status, medical investigations, previous health records, extended health benefits, accident claims and WSIB claims.
I give permission to release any medical files to my health practitioners, my insurer or my legal representative if needed, but not to anyone else.  
Sign

Date

Place

Witness

Sign